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A dual approach to tracheobronchial foreign bodies inchildren
ABSTRACTS mental Studias in Newborn and Two-Week-Old Piglets.
Th. A. Angerpointner, 1t. S/a/linger, O. Linderkamp, et al. Z Kinderchir 36:12-19, 1982. Circulatory adaptation to hypoxemia under anesthetic and surgical conditions was studied in newborn and 2-wk-old piglets using electromagnetic aortic flow measurement. In both hypoxic groups a prompt compensatory, statistically significant increase of cardiac performance appeared within a few minutes of hypoxemia, reaching a maximum 30 min later. Thereafter, cardiac performance decreased steadily leading to cardiac failure. Newborns survived 197 +_96 min and 2-wk-old piglets 172 +_ 128 min. Peripheral vascular resistance decreased significantly at the time of compensatory increase of cardiac performance. This compensatory increase of cardiac performance was more distinct in newborns than in two-week-old animals. Heart rate increased steadily during exposure to hypoxemia in both groups reaching a maximum 110 rain later and falling back to preexperimental values at the end of the study. Newborn normoxic control animals tolerated the experimental model significantly longer (461 _+ 167 rain; p < 0,001) than newborn hypoxic piglets. Their response pattern, however, was basically similar. Two-wk-old normoxic controls responded qualitatively identically with respect to 2-wk-old hypoxic piglets. In all four groups severe metabolic acidosis appeared during the studies, irrespective of hypoxemia or uormoxemia. Stress tolerance depended on the delta pH/hr. In both hypoxic groups stress tolerance correlated well with the increase of heart rate during bypoxemia, whereas this correlation could not be found in the normoxic controls. The authors conclude that anesthetized newborn piglets tolerate surgical stress longer than 2-wk-old animals. When they are, in addition, subjected to hypoxemia, differences disappear. The authors suspect that metaboIic conditions including oxygen transport capacity favor circulatory adaptation to stressful events better shortly after birth than during early i n f a n c y . Thomas A. Angerpointner
The Ethics of In Utero Surgery. If/. R. Barclay, R. ,4.
McCormick, J. B. Sidbury, et al. JAMA 246:1550-1552, (October), 1981. This article is one in a series of "Clinical Perspectives" which appear in the JAMA. Three of the authors have done some very interesting work with the experimental production of hydrocephalus in monkeys and its treatment by the intrauterine insertion of a metal vent which, in the monkeys, successfully prevented the development of hydrocephalus. It is the reviewer's understanding, however, that this procedure has not been successful in humans and, if it were successful, the only thing that it would treat would be hydrocephalus. However, a reader of the "Clinical Perspective" would be left with the following impressions: (1) that the intrauterine vent procedure can be done at a cost of $1,000 (less than the cost of an inguinal herniorrhaphy in Southern California), and that (2) it will prevent all the expensive care required for the management of neural tube defects, the majority of which is incurred by the cost of caring for the paralysis due to the meningocele component that the cephalic vent would not be expected to correct. The participants in the conversation go on to suggest that those doing maternal care may be held
93 legally responsible in the future for failing to see that cephalic vents are inserted in all hydrocephalic fetuses before birth. Doctor Mark Ravich's editorial, "Tell Them More," in the September 1981 Surgical Rounds, should be read as an interesting counterpoint to the above reviewed a r t i c l e . David L. Collins
INTEGUMENT AND CONNECTIVE TISSUE Small Congenital Nevocellular Nevi and the Risk of Cutaneous Melanoma, A. R. Rhodes and J. W. Melski. J Pediatr
100:219-224, (February), 1982. The relative risk of melanoma associated with small congenital nevi was estimated by comparing the published frequency of histologically documented nevocellular nevi in newborn infants with the frequency of: (1) congenital nevi at the tumor site, ascertained by history in 134 patients with melanoma; and (2) tumor-associated nevi with congenital features in 234 melanoma specimens. A 21-fold increase in melanoma risk was estimated for persons with small congenital nevi when nevi were ascertained by history; and a threeto-tenfold increase in risk when nevi were ascertained by histology. The increased risk is related presumably to the markedly increased probability of melanoma arising in association with small congenital nevi.--George Holcomb, Jr.
HEAD AND NECK Nasopharyngeal Airways in Pierre Robin Syndrome. D, P.
Heaf, P. J. Helms, R. Dinwiddie, et al. J Pediatr 100: 698-703, (May), 1982. Nasopharyngeal (NP) airways have been assessed in the management of infants with severe Pierre Robin syndrome (PRS). In 12 such infants the positioning and subsequent maintenance of these tubes were found to be important in ensuring adequate relief of the airway obstruction. In five infants measurements of lung mechanics demonstrated the benefits of NP tube placement and confirmed the observed improvements in cyanotic episodes, heart failure, electrocardiograms, and arterial gas tensions. In a retrospective survey of 40 infants with PRS, failure to thrive was found to be significantly correlated with the severity of the airflow obstruction. This failure to thrive was reversed in the infants managed with NP tubes in comparison with an age-matched group nursed while prone. The lack of significant complications with the NP airway and its acceptability to nursing staff, patients, and their parents suggest that this method deserves more widespread use in PRS and perhaps in other situations in which high upper respiratory tract obstruction is predominant.--George Holcomb, Jr.
THORAX A Dual Approach to Tracheohronchial Foreign Bodies in Children. D. N. Campbell, E. K. Cotton, and J. R. Lilly.
Surgery 91:178-182, (February), 1982. Fifty-seven children were treated for foreign body aspiration, Twenty-nine patients had a foreign body in the trachea or mainstem bronchus which the authors arbitrarily designated central in location. Objects trapped distal to the mainstem bronchus were designated peripheral and occurred in 28 patients. The interval between foreign body aspiration
94
ABSTRACTS
and its removal varied from 2 hr to 6 mo with a mean of 23.8 days and a median of 6 days. The authors describe a treatment plan in which all centrally located foreign bodies are removed bronchoscopically using standard techniques. If all foreign material cannot be removed within one hour, the procedure is stopped and repeated the next day. During the interval, conservative therapy as outlined for the second group of patients is used to attempt to avoid a second bronchoseopy. Conservative therapy for peripherally located lesions employed (1) a broncho dilator via face mask; (2) proper positioning so that the involved segment is upward; (3) percussion of the involved side of the chest by hand cupping; (4) treatments are carried out for 5 minutes each; (5) 6-9 treatments per day. Conservative treatment is only carried out for 48 hr following which it is deemed unsuccessful. Conservative management is contra-indicated for foreign bodies in the mainstem bronchus since dislodgement may result in impaction in the opposite bronchus. Successful removal of the foreign bodies is defined by recovery or by resolution of the symptoms and return to a normal chest x-ray. Of the 29 children with centrally located foreign bodies, the foreign body was successfully removed in all but three who required a second bronehoscopy for residual fragments. Of the 28 patients with peripherally located foreign bodice, 18 (64%) responded to initial conservative therapy, all of whom had had the foreign object present in the airway for less than 14 days. In the 10 in whom conservative management failed, the foreign body had been present for 6 to 180 days, mean 39 days. In these 10, 8 had subsequent successful removal by bronchoscopic techniques. In the remaining two with bronchoscopic failure, resumption of conservative treatment eventually resulted in removal of the foreign body in one child while bronchotomy was ultimately required in the lther. The mean hospital stay for children treated by bronchoscopy was 3.4 days while the conservatively treated children stayed for a mean of 4.2. days.--Eugene S. Wiener HEART AND GREAT VESSELS Surgical Closure of Patent Ductus Arteriosus Outside the Operating Theater. J. 14/. Pate, S. Korones, and C. Sara-
sohn. World J Surg 5:873-875, (November), 1981. The authors report the first nine consecutive PDA ligations performed in their neonatal intensive care unit under local anesthesia. All nine neonates (average weight 1553 g) had failed medical management, including indomethacin in eight. All survived and were successfully weaned from ventilatory support (5-35 days; mean, 11 days). There were no wound infections.--Randall 141.Powell Embolization of a Blalock-Taussig Shunt in a Child. jr. A, G.
Culham, T. lzukawa, J. E. Burns, et al. Am J Roentgenol 137:413-415, (August), 1981. After a second Blalock-Taussig shunt a 39/~2 year old female with tricuspid atresia developed intractable congestive heart failure due to excessive pulmonary flow. The left shunt was occluded with a modified steel coil (first attempt embolized to the left lower lobe). A chest radiograph 5 days following the procedure revealed decreased pulmonary flow and heart size. The child succumbed to persistent left ventricular failure with no post-mortem performed. The authors
state that this represents the first report of an embolic closure of a Blalock-Taussig shunt but feel that specially shaped detachable balloons will be the device of choice for this procedure when commercially available in appropriate sizes.--Randall W. Powell
A L I M E N T A R Y TRACT Abdominal Esophageal Banding for Esophageal Atresia.
7". Hori, H. Nozawa, H. Hazama, et al. J Jap Soc Pediatr Surg, 18:817-821, (June), 1982. Experience with abdominal esophageal banding in four premature neonates with esophageal atresia and tracheoesophageal fistula are reported. Three patients died of various complications before total correction of esophageal atresia. Removal of banding tape, division of tracheo-esophageal fistula and esophago-esophagostomy were successfully carried out in one patient. Autopsy in one patient that died of intracranial bleeding 44 days after birth showed no stricture at the site of esophageal banding. Histologic examination also showed no remarkable changes in mucosa and muscular coat.--H. S u z u k i Banding of Diatal Esophagus for Tracheo-Esophageal Fistula. N. Harasawa, H. Akiyama, M. Saeki, et al. J Jap Soc
Pediatr Surg, 18:823-828, (June), 1982. Banding of distal esophagus was carried out in two critically ill neonates with esophageal atresia and tracheoesophageal fistula. Despite satisfactory effects of banding, both neonates died of sepsis 3 months after birth. Autopsies disclosed stricture and weakness of the esophageal wall at the site of banding. Histologic studies showed marked degeneration and tearing of the external longitudinal muscle fibers and proliferation of collagen fibers.--H. Suzuki Removal of Blunt Oesophageal Foreign Bodies in Children Using a Foley Catheter. T. H. Ong. Aust Paediatr J 18:60-
62, (March), 1982. During a 3-yr period 25 children with an ingested blunt foreign body lodged in the esophagus were treated by a technique using a Foley catheter to remove the foreign body. In only two cases was the procedure performed under fluoroscopic control. In 23 of the 25 cases, the foreign body was successfully removed; in two instances the foreign body was pushed down into the stomach and subsequently passed out spontaneously without complications. Successful extraction can be achieved at the first attempt without fluoroscopic control, if the Foley catheter is introduced all the way into the stomach before inflating the balloon and withdrawing the catheter with the patient in the lateral position. The technique avoids risks of general anesthesia and esophagoscopy, and the patient can be treated promptly without hospitalization. Contra indications for the use of the technique are the presence of sharp foreign bodies, occluding foreign bodies or those bodies capable of being dismantled.--A. MacKellar Gastroesophageal Reflux in Children. A Clinical Review.
HI. E. Berquist. Pediatr Ann 11:135-142, (January), 1982. Sequelae in children with gastroesophageal reflux include esophagitis, failure to thrive, recurrent pneumonia, apneic
Th. A. Angerpointner, 1t. S/a/linger, O. Linderkamp, et al. Z Kinderchir 36:12-19, 1982. Circulatory adaptation to hypoxemia under anesthetic and surgical conditions was studied in newborn and 2-wk-old piglets using electromagnetic aortic flow measurement. In both hypoxic groups a prompt compensatory, statistically significant increase of cardiac performance appeared within a few minutes of hypoxemia, reaching a maximum 30 min later. Thereafter, cardiac performance decreased steadily leading to cardiac failure. Newborns survived 197 +_96 min and 2-wk-old piglets 172 +_ 128 min. Peripheral vascular resistance decreased significantly at the time of compensatory increase of cardiac performance. This compensatory increase of cardiac performance was more distinct in newborns than in two-week-old animals. Heart rate increased steadily during exposure to hypoxemia in both groups reaching a maximum 110 rain later and falling back to preexperimental values at the end of the study. Newborn normoxic control animals tolerated the experimental model significantly longer (461 _+ 167 rain; p < 0,001) than newborn hypoxic piglets. Their response pattern, however, was basically similar. Two-wk-old normoxic controls responded qualitatively identically with respect to 2-wk-old hypoxic piglets. In all four groups severe metabolic acidosis appeared during the studies, irrespective of hypoxemia or uormoxemia. Stress tolerance depended on the delta pH/hr. In both hypoxic groups stress tolerance correlated well with the increase of heart rate during bypoxemia, whereas this correlation could not be found in the normoxic controls. The authors conclude that anesthetized newborn piglets tolerate surgical stress longer than 2-wk-old animals. When they are, in addition, subjected to hypoxemia, differences disappear. The authors suspect that metaboIic conditions including oxygen transport capacity favor circulatory adaptation to stressful events better shortly after birth than during early i n f a n c y . Thomas A. Angerpointner
The Ethics of In Utero Surgery. If/. R. Barclay, R. ,4.
McCormick, J. B. Sidbury, et al. JAMA 246:1550-1552, (October), 1981. This article is one in a series of "Clinical Perspectives" which appear in the JAMA. Three of the authors have done some very interesting work with the experimental production of hydrocephalus in monkeys and its treatment by the intrauterine insertion of a metal vent which, in the monkeys, successfully prevented the development of hydrocephalus. It is the reviewer's understanding, however, that this procedure has not been successful in humans and, if it were successful, the only thing that it would treat would be hydrocephalus. However, a reader of the "Clinical Perspective" would be left with the following impressions: (1) that the intrauterine vent procedure can be done at a cost of $1,000 (less than the cost of an inguinal herniorrhaphy in Southern California), and that (2) it will prevent all the expensive care required for the management of neural tube defects, the majority of which is incurred by the cost of caring for the paralysis due to the meningocele component that the cephalic vent would not be expected to correct. The participants in the conversation go on to suggest that those doing maternal care may be held
93 legally responsible in the future for failing to see that cephalic vents are inserted in all hydrocephalic fetuses before birth. Doctor Mark Ravich's editorial, "Tell Them More," in the September 1981 Surgical Rounds, should be read as an interesting counterpoint to the above reviewed a r t i c l e . David L. Collins
INTEGUMENT AND CONNECTIVE TISSUE Small Congenital Nevocellular Nevi and the Risk of Cutaneous Melanoma, A. R. Rhodes and J. W. Melski. J Pediatr
100:219-224, (February), 1982. The relative risk of melanoma associated with small congenital nevi was estimated by comparing the published frequency of histologically documented nevocellular nevi in newborn infants with the frequency of: (1) congenital nevi at the tumor site, ascertained by history in 134 patients with melanoma; and (2) tumor-associated nevi with congenital features in 234 melanoma specimens. A 21-fold increase in melanoma risk was estimated for persons with small congenital nevi when nevi were ascertained by history; and a threeto-tenfold increase in risk when nevi were ascertained by histology. The increased risk is related presumably to the markedly increased probability of melanoma arising in association with small congenital nevi.--George Holcomb, Jr.
HEAD AND NECK Nasopharyngeal Airways in Pierre Robin Syndrome. D, P.
Heaf, P. J. Helms, R. Dinwiddie, et al. J Pediatr 100: 698-703, (May), 1982. Nasopharyngeal (NP) airways have been assessed in the management of infants with severe Pierre Robin syndrome (PRS). In 12 such infants the positioning and subsequent maintenance of these tubes were found to be important in ensuring adequate relief of the airway obstruction. In five infants measurements of lung mechanics demonstrated the benefits of NP tube placement and confirmed the observed improvements in cyanotic episodes, heart failure, electrocardiograms, and arterial gas tensions. In a retrospective survey of 40 infants with PRS, failure to thrive was found to be significantly correlated with the severity of the airflow obstruction. This failure to thrive was reversed in the infants managed with NP tubes in comparison with an age-matched group nursed while prone. The lack of significant complications with the NP airway and its acceptability to nursing staff, patients, and their parents suggest that this method deserves more widespread use in PRS and perhaps in other situations in which high upper respiratory tract obstruction is predominant.--George Holcomb, Jr.
THORAX A Dual Approach to Tracheohronchial Foreign Bodies in Children. D. N. Campbell, E. K. Cotton, and J. R. Lilly.
Surgery 91:178-182, (February), 1982. Fifty-seven children were treated for foreign body aspiration, Twenty-nine patients had a foreign body in the trachea or mainstem bronchus which the authors arbitrarily designated central in location. Objects trapped distal to the mainstem bronchus were designated peripheral and occurred in 28 patients. The interval between foreign body aspiration
94
ABSTRACTS
and its removal varied from 2 hr to 6 mo with a mean of 23.8 days and a median of 6 days. The authors describe a treatment plan in which all centrally located foreign bodies are removed bronchoscopically using standard techniques. If all foreign material cannot be removed within one hour, the procedure is stopped and repeated the next day. During the interval, conservative therapy as outlined for the second group of patients is used to attempt to avoid a second bronchoseopy. Conservative therapy for peripherally located lesions employed (1) a broncho dilator via face mask; (2) proper positioning so that the involved segment is upward; (3) percussion of the involved side of the chest by hand cupping; (4) treatments are carried out for 5 minutes each; (5) 6-9 treatments per day. Conservative treatment is only carried out for 48 hr following which it is deemed unsuccessful. Conservative management is contra-indicated for foreign bodies in the mainstem bronchus since dislodgement may result in impaction in the opposite bronchus. Successful removal of the foreign bodies is defined by recovery or by resolution of the symptoms and return to a normal chest x-ray. Of the 29 children with centrally located foreign bodies, the foreign body was successfully removed in all but three who required a second bronehoscopy for residual fragments. Of the 28 patients with peripherally located foreign bodice, 18 (64%) responded to initial conservative therapy, all of whom had had the foreign object present in the airway for less than 14 days. In the 10 in whom conservative management failed, the foreign body had been present for 6 to 180 days, mean 39 days. In these 10, 8 had subsequent successful removal by bronchoscopic techniques. In the remaining two with bronchoscopic failure, resumption of conservative treatment eventually resulted in removal of the foreign body in one child while bronchotomy was ultimately required in the lther. The mean hospital stay for children treated by bronchoscopy was 3.4 days while the conservatively treated children stayed for a mean of 4.2. days.--Eugene S. Wiener HEART AND GREAT VESSELS Surgical Closure of Patent Ductus Arteriosus Outside the Operating Theater. J. 14/. Pate, S. Korones, and C. Sara-
sohn. World J Surg 5:873-875, (November), 1981. The authors report the first nine consecutive PDA ligations performed in their neonatal intensive care unit under local anesthesia. All nine neonates (average weight 1553 g) had failed medical management, including indomethacin in eight. All survived and were successfully weaned from ventilatory support (5-35 days; mean, 11 days). There were no wound infections.--Randall 141.Powell Embolization of a Blalock-Taussig Shunt in a Child. jr. A, G.
Culham, T. lzukawa, J. E. Burns, et al. Am J Roentgenol 137:413-415, (August), 1981. After a second Blalock-Taussig shunt a 39/~2 year old female with tricuspid atresia developed intractable congestive heart failure due to excessive pulmonary flow. The left shunt was occluded with a modified steel coil (first attempt embolized to the left lower lobe). A chest radiograph 5 days following the procedure revealed decreased pulmonary flow and heart size. The child succumbed to persistent left ventricular failure with no post-mortem performed. The authors
state that this represents the first report of an embolic closure of a Blalock-Taussig shunt but feel that specially shaped detachable balloons will be the device of choice for this procedure when commercially available in appropriate sizes.--Randall W. Powell
A L I M E N T A R Y TRACT Abdominal Esophageal Banding for Esophageal Atresia.
7". Hori, H. Nozawa, H. Hazama, et al. J Jap Soc Pediatr Surg, 18:817-821, (June), 1982. Experience with abdominal esophageal banding in four premature neonates with esophageal atresia and tracheoesophageal fistula are reported. Three patients died of various complications before total correction of esophageal atresia. Removal of banding tape, division of tracheo-esophageal fistula and esophago-esophagostomy were successfully carried out in one patient. Autopsy in one patient that died of intracranial bleeding 44 days after birth showed no stricture at the site of esophageal banding. Histologic examination also showed no remarkable changes in mucosa and muscular coat.--H. S u z u k i Banding of Diatal Esophagus for Tracheo-Esophageal Fistula. N. Harasawa, H. Akiyama, M. Saeki, et al. J Jap Soc
Pediatr Surg, 18:823-828, (June), 1982. Banding of distal esophagus was carried out in two critically ill neonates with esophageal atresia and tracheoesophageal fistula. Despite satisfactory effects of banding, both neonates died of sepsis 3 months after birth. Autopsies disclosed stricture and weakness of the esophageal wall at the site of banding. Histologic studies showed marked degeneration and tearing of the external longitudinal muscle fibers and proliferation of collagen fibers.--H. Suzuki Removal of Blunt Oesophageal Foreign Bodies in Children Using a Foley Catheter. T. H. Ong. Aust Paediatr J 18:60-
62, (March), 1982. During a 3-yr period 25 children with an ingested blunt foreign body lodged in the esophagus were treated by a technique using a Foley catheter to remove the foreign body. In only two cases was the procedure performed under fluoroscopic control. In 23 of the 25 cases, the foreign body was successfully removed; in two instances the foreign body was pushed down into the stomach and subsequently passed out spontaneously without complications. Successful extraction can be achieved at the first attempt without fluoroscopic control, if the Foley catheter is introduced all the way into the stomach before inflating the balloon and withdrawing the catheter with the patient in the lateral position. The technique avoids risks of general anesthesia and esophagoscopy, and the patient can be treated promptly without hospitalization. Contra indications for the use of the technique are the presence of sharp foreign bodies, occluding foreign bodies or those bodies capable of being dismantled.--A. MacKellar Gastroesophageal Reflux in Children. A Clinical Review.
HI. E. Berquist. Pediatr Ann 11:135-142, (January), 1982. Sequelae in children with gastroesophageal reflux include esophagitis, failure to thrive, recurrent pneumonia, apneic